Monitoring · HRT
HRT is prescribed and adjusted on symptoms, not on numbers, and NICE is explicit that most women do not need blood levels checked to start or continue it. That is sound guidance and this page does not argue with it. What it does say is where testing earns its place: when you are on a good dose and still not right, when you absorb gels and patches poorly, when you take testosterone alongside oestrogen, when you started before 45, and for the things HRT is meant to protect but nobody measures, which are your cardiovascular and metabolic markers. Those are blood questions, and the answers change what you do next.
Venous draw at 103 UK clinics or at home. Report within 48 hours of the lab receiving your sample. No GP referral.
Last reviewed 17 September 2026
The short answer
If HRT is working and you feel well, you do not need a blood test to prove it. Test when symptoms persist on an adequate dose (to check absorption), when you take testosterone (levels should be monitored), when you had a premature or early menopause, or when you want the cardiovascular, metabolic, thyroid and iron picture that HRT monitoring never includes. Timing matters more than most people realise: oestradiol on gels and patches is read at least three months after a dose change, and what the number means depends entirely on which product you use and when you applied it.
See your prescriber, not a blood test, if
You have unexpected vaginal bleeding on HRT, particularly after six months of settled use or any bleeding after the menopause; a new breast lump; calf pain or swelling, or sudden breathlessness or chest pain, which need same-day assessment for a clot; or a severe new headache or migraine with aura. None of those is answered by a blood panel, and all of them need a clinician promptly.
When it helps
1
The commonest reason to test. If you are on a reasonable dose of gel or patch and still getting flushes, broken sleep and fog, an oestradiol level tells you whether the hormone is reaching your bloodstream at all. A low level means absorption, and the answer is a different route or a higher dose. A good level means the symptoms are coming from something else, usually thyroid, iron or sleep.
2
Testosterone for low libido is prescribed off-label for women in the UK, and British Menopause Society guidance does recommend checking levels before starting and periodically after, to keep you within the female physiological range. This is the one part of HRT where monitoring is standard rather than optional.
3
If your menopause came before 45, and particularly before 40, HRT is replacing hormones you should still have rather than topping up. Guidance supports closer monitoring in this group, and the long-term bone and cardiovascular picture matters more.
4
Started within ten years of menopause, HRT is associated with better cardiovascular and bone outcomes. Nobody measures whether that is happening in you. ApoB, Lp(a), hs-CRP, HbA1c and vitamin D are the markers that show it, and none is part of an HRT review.
5
An underactive thyroid, low ferritin and low B12 all produce exactly the symptoms HRT is being blamed for failing to fix, and all three are commoner in women over 45. This is the single most useful thing a panel adds, because the fix is simple once you know.
6
Tablets pass through the liver first, which is why they raise clotting risk and can shift liver enzymes, triglycerides and thyroid binding proteins in ways patches and gels do not. If you take oral oestrogen, the liver and lipid panel is worth having.
What to test
| Marker | What it tells you on HRT | Timing and interpretation | Panel |
|---|---|---|---|
| Oestradiol | Whether the oestrogen is getting in. Most useful for gels, sprays and patches, where absorption varies widely between women | At least 3 months after a dose change. On gel or spray, apply as normal and test 4 to 6 hours later, or test at a consistent time you can repeat. On patches, mid-patch. Oral oestradiol levels are unreliable and generally not measured | Core hormones in Advanced; full set in Ultimate and Signature |
| FSH | Of limited use once you are on HRT, because treatment suppresses it unpredictably. Useful mainly for confirming menopause under 45 before starting | NICE advises against using FSH to diagnose menopause over 45. Do not judge your HRT by it | Core hormones in Advanced; full set in Ultimate and Signature |
| Testosterone and SHBG | If you use testosterone gel or cream, the level keeps you in the female physiological range. SHBG matters because oral oestrogen raises it and lowers the free fraction | Morning sample, before applying that day's dose, and at least 6 to 8 weeks after starting or changing. Free androgen index is calculated from testosterone and SHBG | Testosterone in Advanced; SHBG and free testosterone in Ultimate and Signature |
| Thyroid (TSH, free T4, free T3, antibodies) | The commonest mimic of failing HRT. Oral oestrogen also raises thyroid binding globulin, which can increase the levothyroxine dose you need | Any time; if you take levothyroxine, take the tablet after the draw, not before | All panels |
| Ferritin, iron studies, B12, folate, vitamin D | Heavy perimenopausal bleeding empties iron stores, and the resulting fatigue and fog get blamed on hormones. Vitamin D matters for the bone protection HRT is partly there to provide | Any time. Ferritin below 30 is deficiency; symptoms common below 50 | All panels |
| ApoB, full lipids, Lp(a), hs-CRP | The cardiovascular picture HRT is meant to help. Oral oestrogen raises triglycerides; transdermal does not. Lp(a) often falls on oestrogen, which is one of the few things that moves it | Fasted, morning. Worth a baseline before starting and a repeat at 6 to 12 months | ApoB and lipids in all; Lp(a) in Ultimate and Signature |
| Liver function (ALT, GGT, ALP) | Relevant mainly on oral HRT, which passes through the liver first | Any time; a rise warrants a conversation about switching to transdermal | All panels |
| HbA1c, fasting insulin | Insulin resistance rises through the menopause transition regardless of HRT, and drives the weight change most women notice around the middle | Fasted, morning | HbA1c in all; fasting insulin and HOMA-IR in Ultimate and Signature |
Progesterone levels are not used to judge HRT; the progestogen is there to protect the womb lining and is prescribed by dose, not level. Guides: menopause, perimenopause, thyroid, ferritin, ApoB, the full hormone panel.
Read it in context
Result 1
Poor absorption, which is common with gels and sprays and affected by where you apply them, skin condition, body weight and how soon you shower. The answer is a prescriber conversation about a patch, a higher dose or a different route, not giving up on HRT.
Result 2
The hormone is getting in, so the problem is elsewhere. In practice that is usually a thyroid that has drifted, a ferritin under 30, a B12 in the grey zone, or sleep that has never recovered. Each is treatable and none of them is HRT's fault.
Result 3
ApoB climbing, HbA1c at 41, fasting insulin up. This is the menopause transition doing what it does to metabolism, and HRT alone does not fix it. It is the most useful thing a panel finds in a woman who feels well, because there is a decade to act in.
Which panel
Advanced
74 biomarkers · £269
Core hormones including oestradiol and testosterone, full thyroid with antibodies, ferritin with iron studies, B12, folate, vitamin D, ApoB and full lipids, hs-CRP, HbA1c, liver and kidney.
View AdvancedThe HRT panel
Ultimate
114 biomarkers · £349
Adds SHBG and free testosterone (essential if you use testosterone, and for reading levels on oral oestrogen), Lp(a), fasting insulin and HOMA-IR, cystatin C and tumour markers.
View UltimateHealth plans
2, 3 or 4 tests · from £706
A baseline and the three-month recheck after a dose change, bought together at a lower price per test, with every report compared against the last.
View health plansClinic draw £19. At-home £39. Morning slot, fasted from 10pm. Tell us your HRT type, dose and when you last applied it in the lifestyle questions; the report reads your results against the product you actually use.
Honest comparison
NICE guidance is clear that HRT is titrated on symptoms and that routine oestradiol measurement is not needed for most women over 45. That is good medicine: the level that makes one woman feel well makes another feel nothing, the ranges are wide, and chasing a number instead of a symptom leads to over-treatment. Anyone selling you a monthly hormone panel to "optimise" your HRT is selling you something you do not need. The exceptions are real and specific, and they are the ones listed on this page: absorption problems, testosterone use, premature menopause, and the markers outside the hormone question entirely. If your HRT is working, spend the money on nothing. If it is not, spend it once on a panel that covers the hormone and the mimics together, and take the result to your prescriber. What to ask your GP for.
After your result
Because a level of 250 pmol/L means something different on a patch, a pump of gel or a tablet, and different again if you applied it four hours ago or yesterday. Tell us what you take and when, and the report accounts for it.
Only they can change your HRT, and they should. A low oestradiol on a decent dose is a strong argument for switching route, and the report gives you the number and the context to make that conversation short.
Hormone levels and symptoms both take that long to settle, and iron and vitamin D take the same time to correct. One recheck at three months usually answers the question for good. Retest plans.
FAQs
Not routinely. NICE says HRT is adjusted on symptoms and that most women over 45 do not need hormone levels checked. Testing is worth doing if symptoms persist on an adequate dose, if you take testosterone, if your menopause was early, or if you want the thyroid, iron and cardiovascular picture that an HRT review does not cover.
There is no single target, which is why levels are not used to titrate treatment for most women. What matters more is whether the hormone is being absorbed at all, and how the level compares with your own previous result on the same product at the same time of day. Interpreting it requires knowing which product you use, the dose and when you applied it.
At least three months. Both symptoms and levels take that long to settle, and testing sooner produces a number that will have changed by the time you act on it.
Use your normal routine and record it. For gels and sprays, testing around four to six hours after application is common, but the most useful thing is consistency, so that your next result is comparable. For patches, mid-patch rather than on the day you change it. If you take testosterone, take the morning sample before that day's dose.
Oral HRT does more than transdermal. It raises SHBG, which lowers free testosterone; raises thyroid binding globulin, which can increase the levothyroxine dose you need; raises triglycerides; and passes through the liver, which can shift liver enzymes. Patches and gels avoid most of this, which is one reason they are often preferred.
Thyroid with free T3 and antibodies, ferritin with iron studies, B12, folate and vitamin D, alongside the oestradiol level to confirm absorption. In practice one of the first four explains it far more often than the HRT dose does.
Advanced and Ultimate reports are delivered within 48 hours of the laboratory receiving your sample. Signature takes around 12 working days.
Hormones, thyroid, iron and the cardiovascular markers in one venous draw, at 103 UK clinics or at home, with a report that reads your levels against the product you actually use.
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